• Leona Mirtschin

What Everybody Ought to Know About Breathing & Coronavirus: Part 1



At no other point in our life is it hitting home that breath is life. With the unfolding of the worldwide coronavirus pandemic it seems it's not just the elderly that are at risk, but adults of all ages. The good news, it's not too late to improve your lung health.


Your respiratory system is your lifeblood. But the truth of the matter is you probably haven't paid much attention to your breathing, likely because breathing happens automatically under your subconscious control, you don’t have to remember each time to take a breath.

But how well you breathe could influence how swiftly your body can deal with respiratory diseases. The health and efficiency of your lungs and airways are vital to staying alive and even more so when you are struck down with pneumonia, which causes inflammation of your airways.


While this seems unconvincing to some, it's worth taking a look back in history 100 years to the Spanish flu pandemic, which emerged at the end of World War 1 in 1918. Reports say that it killed 50 million-plus people worldwide, while in Australia, 40 percent of the population contracted the illness and 15,000 died as a result.


What was unique about the Spanish flu was that it did not just affect the more vulnerable population of the very young and the elderly, but affected young adults aged 20-40 years in droves.


Joseph Pilates and the Spanish flu pandemic

When World War 1 broke out in 1914, Joseph Pilates was a performer in a circus act touring England. As a German national, he was interned for the duration of the war on the Isle of Man, where close to 24,000 fellow German prisoners of war were detained. While in the camp Pilates was one of the physical leaders who led the daily exercise routine for the detainees in his compound.


It was during his internment that Pilates had the opportunity to study the thousands of books on sport, medicine and anatomy in the camp library and the opportunity to help many of his fellow detainees who were suffering from the problems of body and mind induced internment. It was over these three and a half years that he had time to think and time to develop his methodology, which focuses on the importance of exercise to maintain physical and mental wellbeing.


When the influenza pandemic broke out in 1918, none of the detainees who followed his regime got sick. Joseph's success with his group of detainees brought him to the attention of the camp leaders, and he was given the job of a hospital orderly. In charge of 30 war-injured patients, he worked with them every day to exercise whatever they could move. A proud accomplishment of Pilates’ bed exercises that utilised the springs from the hospital beds, not only helped his patients to get better faster but also helped them to avoid deadly influenza that killed so many injured soldiers.

Breathing and the Pilates Method

Breathwork is a key concept of Pilates Method and is one of the first things that I assess and teach all my clients whether they are seeing me for chronic back pain, shoulder injuries, diabetes, and depression through to osteoporosis and leg circulation issues.


Over 20 years, I could count on my hands the number of people who could breathe correctly first up. One reason for this is very few people are even aware of how they breathe and secondly, proper breathing has never been taught to them. That is unless they’ve had reputable instruction in the Pilates Method, yoga or meditation.


I had a lady come in and see me with chronic back pain so bad that she was anxious and teary with how weak she felt. Her personal trainer had told her she had great core strength because she could hold a 5-minute plank, so she couldn’t understand why she felt so debilitated. I assessed her breathing, and it was one of the shallowest breath patterns that I had ever seen. She was breathing high into her chest and there was so much tension in her neck that her shoulders were lifting each time she took a breath in. She was using her neck muscles to breathe and not her diaphragm.


The diaphragm is one of four muscles of your inner core, along with transversus abdominus, pelvic floor and multifidus. You can visualise these four muscles like a muscular cylinder. It could be said that the function of your diaphragm is the most important to get right. That’s because if you are not using your diaphragm to breathe, that is if your breath is shallow and in your chest, your inner core muscles can’t function correctly to give your body that corset-like support for your spine.


If you don’t have this “core foundation” there will be weakness throughout your whole body.

Without proper diaphragm function, breathing is poor and respiratory function is inefficient at getting oxygen into your bloodstream, something that every cell in your body depends on to survive.


With ageing, a decrease in the strength of respiratory muscles causes impairments in the performance of functional activities. A study in elderly women found inspiratory muscle training associated with the Pilates method provides an improvement in both lung function and physical conditioning.


Breathing and respiratory function

Your lungs are like an upside-down tree, with a trunk that forks into two major branches and then progressively smaller and smaller branches, into twigs that end in grape-like fruit.

These grape-like fruit at the end of your respiratory "tree" are microscopic air sacs called alveoli. There are approximately 500 million alveoli in the lungs and they have a surface area of 140 square metres, which is about the size of a tennis court. This is where the gas exchange takes place.


Blood that has returned to your lungs from around your body via the heart, flows through the alveoli and expels carbon dioxide into your lungs to be exhaled, and in return takes up fresh oxygen from the air that you have breathed in. The alveoli are not equally efficient in this gas transfer over the whole of the lungs.


The small airways including the alveoli are elastic and stretch wide open on maximal inhalation. Some of these small airways tend to collapse shut, especially in the lower lungs. When the alveoli air sacs collapse, the air becomes trapped inside them, so that when you next inhale not as much fresh air can enter these alveoli. Along with “stale” air that has been hanging around, the result is less efficient oxygenation of the blood and elimination of carbon dioxide from the blood. The ability of your alveoli to stay open determines how much surface area is available for gas exchange, and is essential for your respiratory health.


The Fletcher Pilates Percussive Breath Technique TM

In his New York City studio, Joseph Pilates, in a thick German accent, would incessantly command his students, including Pilates Elder Ron Fletcher, to “Breeze!” That’s “breathe” followed by “You must OUT de air to IN de air” a continual reminder to breathe fully and deeply.


Joseph Pilates was insistent to the importance of breath, as found in his books and films, and as told by Pilates Elders, those who studied under him. You could arguably say that breathing was Pilates’ most important principle. A famous quote from his published book ‘Return to Life Through Contrology’ (Pilates original name for his method) says it plainly “…above all, learn how to breathe correctly.”


It was Ron Fletcher who refined the Pilates breathing technique, which involves exhaling air with the mouth airway narrowed. This creates a form of resistance to the out-breath. While the inhale breath is always through the nose, the exhale breath is through thin lips like you are blowing up a balloon or cooling a hot cup of coffee or tea, and with the tongue against the palate (although I have to say I still find this difficult with the tongue position). This percussive breathing style creates the signature “shush” sound, which by the way is a by-product from the activation of your core musculature.


Percussive breathing trains you to breathe deeply and fully using “the breathing apparatus,” as Ron Fletcher termed it. This means using your diaphragm and entire core muscles, together with your thoracic and intercostal muscles to expand your ribs allowing more space for your lungs to expand.


The emphasis is on the exhale breath for good reason. When you exhale completely, this engages the external oblique muscles to squeeze your lower rib cage inwards, and remove the air out of the deepest portions of your lungs. When you remove the air out of your lower lungs, then the inhale breath automatically floods oxygen-rich air into the deepest parts of your lungs, expanding your ribcage like an umbrella and increasing your lung capacity.


Narrowing your lips when breathing out creates resistance to your exhales, causing a back pressure down to your microscopic alveoli air sacs. This small backpressure resists the tendency of the alveoli to collapse and instead encourages them to stay open. This has the effect of increasing the surface area of the alveoli, which increases the efficiency of gas exchange between oxygen and carbon dioxide in the bloodstream as it passes through the alveoli.


One thing I learnt as a beginner going through my Fletcher Pilates teacher training and what I see with my clients, is that when you are learning the percussive breath method you can get carried away with the “shushing” out-breath that you speed up your breath like a steam train. Your breath needs to be slow with softness to it, so you avoid unwanted tension and feel your breath make full use of your lungs and revitalise your body and mind with oxygen.

What happens in COVID-19 patients?

According to a Lancet study from Wuhan the COVID-19 epicentre, published data on 41 patients that were hospitalised with the novel COVID-19 virus found:

  • The most common symptoms at the onset of the illness were: Fever (98%), cough (76%) and fatigue (44%)

  • Shortness of breath and difficulty breathing developed 8 days from the onset of the illness in 55% of patients

  • Acute Respiratory Distress Syndrome (ARDS) developed in 29% of patients with severe illness, 9 days from illness onset and required ICU admission and oxygen therapy 10.5 days from illness onset

  • All patients (100%) had pneumonia – an infection that inflames the air sacs in one or both lungs

  • The average respiratory rate of all patients was greater than 24 breaths per minute (indicating an extremely shallow breathing pattern – the normal respiratory rate for adults is 12-16 breaths per minute but I prefer to advocate a slow breathing rate of 6-10 breaths per minute)


In patients with Acute Respiratory Distress Syndrome, the whole lung becomes inflamed. With inflammation, fluid leaks into the alveoli air sacs and prevents oxygen from getting into the bloodstream. This causes a lack of oxygen or hypoxia and difficulty breathing and shortness of breath.


Along with mechanical ventilation, one of the treatment protocols advocated in patients with ARDS is inclined sitting position and prone positioning (lying on your front) as opposed to supine positioning (lying on your back). A study published in the New England Journal of Medicine found prone positioning significantly reduced mortality from 33% in supine positioning to 16% in prone positioning.


Prone positioning places less stress on the lungs and increases oxygenation, by better matching the airflow to blood flow in all alveolar units. Additionally, prone posture may prevent pooling of secretions in the base of the lungs by promoting clearance of oedema fluid from the alveolar space.



Diagram sourced from Nicholas et al. Gas exchange in the prone posture, Respiratory Care. In the supine posture, there is close matching of the gas exchange (ventilation Vdot) and pulmonary blood flow (perfusion Qdot) in the ventral lung but markedly poor matching in the dorsal lung, resulting in a wide distribution of ventilation in perfusion (middle and right). In the prone posture, ventilation and perfusion are more closely matched throughout, resulting in a tighter distribution of ventilation/perfusion ratios.


Take a deep breath

Breathing patterns are influenced by your psychological state of mind and vice versa – bad news and stress causes you to breathe shallow and take more breaths per minute. Without you realising it, watching the unfolding coronavirus pandemic on TV causes your breathing to become more rapid and shallow, you will likely feel sick in the stomach and feel anxious. This is your body’s stress response.


On the other hand, deep breathing helps calm your body of physical tension and ease your mind from psychological and emotional stress – something that we all need right now amidst the coronavirus pandemic. Deep breathing has been shown to counteract the stress response and switch it off. It does this by stimulating the vagus nerve and parasympathetic nervous system, which calms your nervous system right down. A 10-second breath cycle (a 5 second inhale and a 5 second exhale) has been shown to elicit the relaxation response and is effective in the treatment of depression and anxiety, in pain management and has also shown to have anti-inflammatory effects.


Conscious deep breathing connects your mind with your body and it does this by connecting breath with your deep and innermost centre. In the Pilates Method, we call this breathing and centring, using your breath to connect with your core powerhouse.


Your breath is an anchor to the present moment and your being, your being that doesn’t judge or criticise, worry or fear the future, or beat yourself up about the past. When you breathe deeply you are connecting your mind with your body and bringing awareness to your being, accepting the present moment as it is without judgement or fear. It has also been said that connecting with your centre helps you to heal whatever you are dealing with, be it physical or mental dis-ease.


Mother nature has tremendous power in the way she works when the earth is out of balance. COVID-19 is making us live differently, rethink our lives and is perhaps making each one of us realise what is most important in our fragile life.


Breathing well not only empowers you to keep your respiratory system in good health and your body flooded with oxygen but also helps you to stay calm and keep stress levels at bay. If you contract coronavirus or other respiratory diseases, then practising the percussive breath method can get you back on feet to better health much faster and stronger.


Next up:

What Everybody Ought to Know About Breathing & Coronavirus Part 2 - Best Exercises to Improve Your Lung Health


About the author: Leona Mirtschin is an Accredited Exercise Physiologist and a 3rd generation Pilates practitioner certified in the Pilates Method (BASI) & Licenced Fletcher Pilates Provider

References


Alvarenga GM, Charkovski SA, Santos LKD, Silva MABD, Tomaz GO, Gamba HR. The influence of inspiratory muscle training combined with the Pilates method on lung function in elderly women: A randomized controlled trial. Clinics (Sao Paulo). 2018;73:e356. doi:10.6061/clinics/2018/e356


Bernardi L, Sleight P, Bandinelli G, et al. Effect of rosary prayer and yoga mantras on autonomic cardiovascular rhythms: comparative study. BMJ. 2001;323(7327):1446–1449. doi:10.1136/bmj.323.7327.1446


Fletcher Pilates Blog. Fletcher Pilates Percussive Breath TM Technique, June 2019.


Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome. N Engl J Med. 2013;368(23):2159–2168. doi:10.1056/NEJMoa1214103


Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China [published correction appears in Lancet. 2020 Jan 30;:]. Lancet. 2020;395(10223):497–506. doi:10.1016/S0140-6736(20)30183-5


Johnson NJ, Luks AM, Glenny RW. Gas Exchange in the Prone Posture. Respir Care. 2017;62(8):1097–1110. doi:10.4187/respcare.05512


Johnson RL, Wilson CG. A review of vagus nerve stimulation as a therapeutic intervention. J Inflamm Res. 2018;11:203–213. Published 2018 May 16. doi:10.2147/JIR.S163248


Kallet RH. A Comprehensive Review of Prone Position in ARDS. Respir Care. 2015;60(11):1660–1687. doi:10.4187/respcare.04271


Mautz William J, PhD, Physiological Benefits of the Fletcher Pilates Percussive Breath Technique, University of Hawaii at Hilo, Fletcher Pilates Intensive Licencing Course notes


Marc A. Russo, Danielle M. Santarelli, Dean O’Rourke. The physiological effects of slow breathing in the healthy human. Breathe Dec 2017, 13 (4) 298-309; DOI: 10.1183/20734735.009817

Yang J, Phi JH. The Present and Future of Vagus Nerve Stimulation. J Korean Neurosurg Soc. 2019;62(3):344–352. doi:10.3340/jkns.2019.0037



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